NURSES PERCEPTION OF PREOPERATIVELY

FASTING PATIENTS AND COMMUNICATION WITH THEATRE STAFF

&
HOW THIS DIFFERS TO WHAT CURRENT EVIDENCE BASED RESEARCH SUGGESTS

CONTENTS

TITLE

~~~~~~~~~~~~~~~~~~~~~~~~~~~~~ PAGE. ~~~~~~~~~~~~~~~~~~~~~~~~ PAGE.

1 2 3-4 4-6

CONTENTS

INTRODUCTION ~~~~~~~~~~~~~~~~~~~~ PAGE. DEFINITION OF TERMS ~~~~~~~~~~~~~~ PAGE.

HISTORY & PATHIOPHYSIOLOGY OF ASPIRATION PNEUMONITIS ~~~~~~~ PAGE. 7-9 10-18

LITERATURE REVIEW ~~~~~~~~~~~~~~~ PAGE. CODE OF CONDUCT LEGAL IMPLICATIONS ~~~~~~~~~~~~~~ PAGE.

18-19

PREOPERATIVE FASTING IN THE UK & OVERSEAS ~~~~~~~~~~~~~~~~~~~~ PAGE. ~~~~~~~~~~~~~~~ PAGE. 19-22 22-25 26-28 29-33 34-35 36-37

RECOMMENDATIONS

CONCLUSION ~~~~~~~~~~~~~~~~~~~~~~ PAGE. REFERENCE LIST ~~~~~~~~~~~~~~~~~~~ PAGE.

APPENDIX 1 ~~~~~~~~~~~~~~~~~~~~~~~ PAGE. APPENDIX 2 ~~~~~~~~~~~~~~~~~~~~~~~ PAGE.

Introduction

From my time as a student nurse I have worked on both surgical and medical wards. I have found in both these areas patients who have been preoperatively fasted have often been Nil by mouth from midnight if they are on the next day morning list. Those on the afternoon list are nil by mouth after a light breakfast on the day of surgery. It has, become custom and practice in many clinical settings to deprive patients both food and fluids for unnecessarily long periods of time. Often when I asked the nurse in charge why patients were fasted for so long, I was been told Its always been done this way or The theatre staff like us to do it this way. So I decided to look at the research available and see how long a patient should be fasted from food and fluids? How this is reflected in current nursing practice and how it impacts the patient in a psychosocial and psychological aspect.

The preoperative fasting of surgical patients before having a general anaesthetic is a widely established clinical practice. It is considered essential in reducing the chances of vomiting and regurgitation and the possible aspiration of gastric contents during anaesthesia (Seymour 2000). However most hospital trusts dont appear to have standard policies or guidelines of the specific times a patient should be fasted for. The decision is then left up to the anaesthetist or the nurse in charge of the ward.

Definition of Terms

To fast which means to abstain from eating and drinking for a limited period as stated by the Cambridge English dictionary is the commonly used term in nursing. Anyone having elective surgery is fasted for a period of time to reduce the risk of vomiting during induction. HamiltonSmiths study (1972) found that health professionals understanding of how long this period of time should be were very varied often based on tradition rather than evidence based. In the National Health Service
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(NHS) under the current Labour government the term evidence based means the process of systematically finding, appraising and using research findings as the basis for clinical decisions Royal College of Nursing (2005). The Royal College of Nursing goes on to describe evidence based clinical practice as involving making decisions about care of individual patients, based upon the best available research evidence, rather than nurses personal opinion or common practice (which may not be evidence based). Evidence based clinical practice involves integrating individual clinical expertise and patient preferences with the best available evidence from research. If we as nurses are to bring nursing as a profession up to date we need to utilize this evidence to provide the best care for our patients. Dimatteo (1994) sees Communication as the fundamental instrument by which health care professionals and patient relate to each other in an attempt to achieve therapeutic goals. Where as Owens (2002) defines Communication as the process of exchanging information and ideas. According to Light (1997) communication involves relating to others, affecting them and letting them affect you. Light (1997) further claims that the four main purposes of communication are exchanging

information, conveying wants and needs, establishing social closeness and adhering to social etiquette.

Communication is defined as an interchange of thoughts feelings and opinions among individuals. Verbal communication is effective when it satisfies basic desires for recognition, participation and self-realization by direct personal contact between persons. There is general assumption that effective communication is achieved when open two-way communication takes place, and patients are informed about the nature of their illness and treatment and are encouraged to express their anxieties and emotions. This view assumes that open communication, full information about a disease and its prognosis, has benefits for all patients.

History and Pathophysiology of Aspiration Pneumonitis

The current practice of recommending nil by mouth after midnight until the time of surgery is widely believed to have originated from Mendelsons study in 1946. Mendelson described the pathophysiology of acid aspiration through research in to 44016 obstetric patients receiving general anaesthesia in a New York hospital between 1932 and 1946. Mendelson recorded 45 cases of aspiration, 40 aspirated liquid while the remaining 5 aspirated food which caused an obstruction and led to the deaths of two patients from suffocation. These two patients had ingested a full meal, one 8 hours previously and the other 6 hours previously. In his conclusion he proposed that a reduction in aspiration under general anaesthesia would be achieved by: emptying of the stomach before general anaesthesia; and adequate equipment (a tilting table, transparent anaesthetic masks, suction and equipment for tracheal intubation. Later on, these preventative measures were extended to other forms of surgery. The number of aspirations in all patients having a general anaesthetic was reduced to 1-10 in 10,000, which equates to 0.01-0.1% (Mellin-Olsen et al 1996; Flick et al 2002). Less than 5% of these aspirations resulted in
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death, and the mortality rate following aspiration overall was between 0 and 2 in 10,000 (Ng & Smith 2002; Flick et al 2002). Hillier (2006) states prolonged fluid deprivation has been shown to increase the volume and decrease the ph of gastric juices, both of which increase the likelihood and consequences of gastric acid aspiration. A study by Agarwal (1989) provides supporting evidence of detrimental health attributed to prolonged fasting, arguing that patients who endure excessive periods of fasting actually increase their gastric volume, and thus predisposing patients to aspiration pneumonitis. The opposite of a prolonged fasting time is that of an inadequate fasting time, which can also have a detrimental effect. If the length of preoperative fasting is too short a patient may potentially aspirate the contents of their stomach in to their lungs, which could also lead to aspiration pneumonitis, according to Olsson et al (1986), occurring in 1-6% of every 10,000 administered anaesthetics.

Aspiration pneumonitis

This does represent a small percentage risk, but in absolute terms this could be a large number of patients, given that an estimated 6 million people in the UK alone have surgery under a general anaesthetic each year, Department of Health (2005).

Literature Review

My literature search included: textbooks on preoperative fasting, metabolic effects of fasting and surgery textbooks; manual journal searches; and the use of various computerized databases. These databases included Medline, CINAHL & Nursing Collection. Keywords for database searches included the following: nil by mouth, fasting guidelines, preoperative care, and evidence based research. These searches yielded over a five hundred articles, of which around 40 were relevant to my project. I initially decided to compare and analyse Hamilton Smiths (1972) study and Hung's (1992) study. The reason behind this was that Hungs (1992) study replicated Hamilton Smiths (1972) study which investigated the practice of preoperative fasting procedures in hospitals. As there was a 20 year gap between the two studies I could review these and compare the findings and analyse if and how things had changed. Then from this I could review current studies and proposed recommendations that had taken place up to 2006 and further compare and analyse this to see how

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the role of the nurse had changed and how the available evidence based research had been utilised by nurses in clinical practice.

Hamilton Smiths (1972) study found there was no hospital or ward policy regarding preoperative fasting procedures. Without an agreed policy or guidelines there was no clear means of establishing a uniformity of practice and there were considerable variations in the interpretation and execution of this specific preoperative care. Hungs (1992) study also came across the same problem of there being no clear hospital or ward policy. Hamilton Smith (1972) found that anaesthetists acknowledged ultimate responsibility for patients having surgery under a general anaesthesia and decided how long they should be preoperatively fasted for. However this differs with Hungs (1992) study which found that the majority of anaesthetists left the responsibility and execution of minimum fasting times up to the nurses on the ward. Jester and Williams (1999) sides with Hamilton Smith (1972) that; Wherever possible, the anaesthetists should prescribe the latest time for food and fluids. When this is not done, nurses should feel

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empowered enough to ensure patients receive fluid preoperatively up until a safe and appropriate time. Hamilton Smith (1972) found nurses agreed that the minimum time should be between 4 and 6 hours for food (65%) and 4 hours for fluids (58%). However there was no established or agreed maximum fasting time. This was similar to Hung (1992) but anaesthetists and nurses cited a variety of maximum fasting times ranging from 4 to 24 hours without intravenous infusion. The average maximum fasting time agreed by a significant proportion of anaesthetists and nurses was 12 hours. Opinions on when solids or milky fluids (containing fat, which has been proven to be slower to digest) can be taken between 4 and 8 hours preoperatively. The American Society of Anaesthesiologists (1999) recommends solids or milky drinks should not be taken for 6 hours preoperatively. They also suggested that clear fluids should be stopped 2 hours preoperatively and went on to clarify clear fluids to include, but are not limited to water, fruit juices without pulp, carbonated beverages and tea or coffee without milk. In 2005 the Royal College of Nursing published guidelines for the UK after analysing evidence from American Society of Anaesthesiologists (1999). They concluded that adults who are in good health without GI

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disorders can drink water up to 2 hours before induction of anaesthesia. Clear fluids (those which newsprint can be read through) including clear tea and coffee up to 2 hours before induction of anaesthesia. Food to include tea or coffee with milk can be taken 6 hours before induction of anaesthesia. The Royal College of Nursing Perioperative fasting in adults and children guidelines can be seen in Appendix 2. In both Hamilton Smith (1972) and Hung (1992) studies the practice of preoperative fasting procedures was predominantly governed by nursing tradition and ritualistic based practice. Seymour (2000) identifies that tradition and custom often dictate preoperative fasting regimens rather than the patients need. This view is supported by Pandit and Pandit (1997). This meant that patients on the morning theatre list were all fasted at the same time (midnight) irrespective of their position in the list. All patients on the afternoon theatre list were fasted on the morning of surgery after a light breakfast. This resulted in the majority of preoperative patients being deprived of food and fluid for a considerable length of time. Other reasons often cited by nurses for such long fasting times included the constantly changing operating lists. Since it was expected that all patients on the same list were fasted at the same time,

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keeping wards informed of changes by theatre staff to the operating list seemed pointless as this didnt alter the patients fasting regime. It was no surprise to find communication between theatre staff and ward nurses was poor and there was confusion as to who should be overall responsible for keeping the wards up to date in the event of changes to the list. From this Hung (1992) observed that the procedures in place were more for the conveyance of theatre staff and ward nurses, than for the wellbeing of patients.

The detrimental effects of prolonged preoperative fasting can be divided in to two broad categories psychosocial and physiological. Hamilton Smith (1972) conducted a study assessing the opinions of anaesthetists and nurses regarding preoperative fasting. Twenty years later Hung (1992) replicated this same study to ascertain whether preoperative fasting procedures had changed. Both of these studies concluded that despite a good knowledge of the possible complications caused by prolonged preoperative fasting, anaesthetists and nurses reported that it was still common for patients to be fasted in excess of 12 hours. A summary of

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potential complications caused by excessive preoperative fasting is set out below:

PSYCHOSOCIAL Confusion Irritability Social isolation of missed meals Anxiety due to lack of information and poor communication

PHYSIOLOGICAL Dehydration Headaches Hypoglycaemia Electrolyte imbalance Nausea/vomiting Jester & Williams (1999)

Patients who are fasted for long periods of time may experience some or all of these effects, depending on their health prior to fasting. Rowe (2000) adds that, when patients are fasted for long periods of time, the body will draw on its own reserves and enter in to a period catabolism that might leave the patient with considerably less strength and energy to negotiate post-operative recovery. Also older people, often chronically dehydrated, might be at a greater risk in these circumstances (Jester and Williams 1999). Arndt (1999) states that patients who have fasted for

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more than eight hours are more prone to hypothermia, due to the loss of heat produced by digestion. This has a greater importance for older people as they have relatively less body fat than healthy adults. However, OCallaghan (2002) points out that the reason for prolonged preoperative fasting may be a lack of nursing knowledge regarding long term complications. Having performed a literature search I wanted to know why, when so much evidence based research is now easily available, do patients still go through such long periods of preoperative fasting?. A summary of the main reasons that patients have to endure such long periods of fasting is provided below:

Lack of knowledge Evidence based material relating to preoperative fasting used to be mainly found in anaesthetic journals; however this information is slowly becoming more widely available to all health professionals.

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No uniformity of practice In many hospitals there are no recorded policies or guidelines relating to preoperative fasting. Practice tends to be tradition led rather than evidence based. Custom and routine Governed by custom and routine means patients on the same theatre list, irrespective of their position, are fasted for the same amount of time. This relates as fasting from midnight for the morning list or, fasting after a light breakfast on the day of surgery for the afternoon list. Changes in theatre lists Apparent difficulty in obtaining accurate operating times further prevents the planning of individual regimes. Lack of communication and, poor communication between theatre staff and ward nurses can lead to confusion over whose responsibility it is to inform ward nurses of any changes.

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Tradition There is assumption that everyone is doing the same thing as everyone else; thus reinforcing tradition and reflecting the deficiency in sharing ideas. (Gathered from work by Chapman 1996, Hamilton Smith 1972, Philips 1993, Thomas 1987)

Code of Conduct Legal Implications

Seymour (2000) states that tradition and custom often dictate preoperative fasting regimes rather than the patients individual needs. Pandit and Pandit (1997) found the fasting of patients from midnight the night before surgery is a very common practice in the National Health Service and the private sector. However the Nursing and Midwifery Councils Code of Professional Conduct (2004) states that patients should be treated as individuals, which means nurses should accurately assess, plan, implement and evaluate individualised care plans for all patients. The Nursing and Midwifery Council also advocates professional knowledge and competence must be maintained throughout the working life of

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practitioners. This includes ensuring practitioners have adequate knowledge in order to facilitate appropriate fasting regimes. The findings of Seymour (2000) and Pandit and Pandit (1997) go on to suggest that this in fact is not happening. If nurses are not up to date with current evidence based research and practices, it is not a legal defence against misconduct. This assertion is supported by the Nursing and Midwifery Council (2004) which states that practitioners have a professional responsibility to deliver care that is based on current advice, best practice and where applicable, validated research when it is available. If patients are fasted for excessive periods of time or have not been fasted sufficiently and therefore suffer discomfort or complications during the anaesthetic procedure as a result, this can become a legal matter.

Preoperative Fasting in the UK and Overseas

The guidelines of the Scandinavian Society of Anaesthesiology and Intensive Care Medicine for preoperative fasting in elective patients (2006) represent the most recent up to date research and summarize the

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recommendations of various other national and society guidelines. Table below:

Patients (adults and children) may drink clear fluids up to 2hours

prior to general or regional anaesthesia

Patient should not take solid food 6 hours prior to induction of

anaesthesia

Breast-feeding should be stopped 4 hours prior to induction of

anaesthesia; the same applies to formula milk

Adults may drink up to 150ml water with preoperative oral

medication up to 1 hour prior to induction of anaesthesia

Use of chewing gum and any form of tobacco should be

discouraged the last 2 hours prior to induction of anaesthesia

The Scandinavian Society of Anaesthesiology and Intensive Care Medicine 2006) defines clear fluids as non-particulate fluids without fat: for example, water, clear fruit juice, tea or coffee. Both cows milk and powdered milk are treated as solid food. These Scandinavian Society of Anaesthesiology and Intensive Care Medicine (2006) guidelines differ
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compared to the UKs Royal College of Nursing (2005) guidelines in that adults are allowed 150ml of water when taking medication up to 1 hour before induction of anaesthesia, and children up to 75ml. Whereas the Royal College of Nursing (2005) guidelines only allow 30ml fluid when taking medication for adults and 0.5ml per kg for children. Another difference with the Scandinavian Society of Anaesthesiology and Intensive Care Medicine (2006) guidelines includes chewing gum and any form of tobacco should be discouraged 2 hours prior to induction of anaesthesia. Whereas the RCN states that chewing gum is not permitted on the day of surgery. It doesnt specify whether or not the patient can take or smoke tobacco preoperatively. So in theory a patient in the UK under the Royal College of Nursing (2005) guidelines can chew gum up to midnight the day before surgery and if smoking facilities are available within the hospital they can smoke right up until they go to theatre. The remaining guidelines for both countries are the same in every aspect. The common argument against modern fasting guidelines is that the traditionally followed nil by mouth from midnight is believed to allow the greatest flexibility for the operating team. Soreide and Ljungqvist

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(2006) state in their experience, this fear is unsubstantiated. They go on to say The change of guidelines develops better communication between operating staff and the ward where the patient is waiting. This has in many cases improved patient flow through the system.

Recommendations

A patient who is fasted preoperatively for the correct amount of time before elective surgery is integral to safe practice. Nurses should be aware that patients should be treated as individuals by promoting the interests of patients in their care. It is essential that this practice must become patient centred rather than restricted by theatre or ward traditions Nursing and Midwifery Council (2004).

The literature I have reviewed taken from current evidence on preoperative fasting has made little change to the traditional ward orientated management of fasting regimes. The lack of implementation has resulted in prolonged preoperative fasting of patients. This can have a

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detrimental effect both psychosocially and psychologically to patients. This resulted in the recommendations below proposed by Oshodi (2004).

For evidence based practice to be a reality, factors that can hinder

the application of research to practice should be identified and addressed

More up to date research in to how nurses could implement

evidence based individualised preoperative fasting is needed

Where trust guidelines are not yet in place, nurses should feel
empowered to negotiate with other professionals appropriate fasting periods that are based on current evidence, as they have to act in the patients best interest

Nurses on the ward should collaborate more with surgeons,

anaesthetists and theatre staff to keep abreast with changes in the theatre list. This would help nurses to act responsively if there was a cancellation or addition to the theatre list ( i.e. to withhold fluid from patients whose name has to move up the list; to provide food for patients whose name has been cancelled from the list to prevent unnecessary starvation; or to provide clear fluids or toast up to a

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safe limit for patients whose names have been pushed down the theatre list)

Ongoing education on preoperative fasting evidence and the

detrimental effects and complications of excessive preoperative fasting should be provided to surgical nurses at ward level to reaffirm the importance of patients being fasted appropriately

It wasnt until 2005 that the Royal College of Nursing published its own recommendations gathered from evidence based research entitled Perioperative fasting in adults and children The Royal College of Nursing (2005) provided as part of the publication an A4 poster shown in Appendix 2. This states that clear fluids can be taken up to 2 hours before induction of anaesthesia for elective surgery in healthy adults, and that this improves the wellbeing of the patient. Hillier (2006) agrees with this recommendation based on current research and evidence. The Royal College of Nursing (2005) defines clear fluids as tea and coffee without milk or any other fluid through which newsprint can be read. Hillier (2006) explains that the term clear fluids is too vague and

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should be removed and substituted with a short list of fluids acceptable to anaesthetists. The intake of solid food should have a minimum fasting period of 6 hours as recommended by the Royal College of Nursing (2005). Whereas Hillier (2006) recommends patients should only be starved of solids for 4 to 6 hours. Chewing gum should not be permitted on the day of surgery and, sweets should not be eaten 6 hours before induction of anaesthesia Royal College of Nursing (2005). Hillier (2006) goes further in recommending that the lack of practitioners knowledge needs to be addressed by implementing agreed well published, trust wide policies for preoperative practice. Also changes to theatre lists should be kept to a minimum for safety reasons and through good communication skills between theatre staff and ward staff nurses are able to manage patients preoperative fasting time effectively.

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Conclusion The current practice used on most wards of prolonged fasting carries potential risks and therefore needs to be addressed and changed. Many valuable and practicable suggestions have been proposed by anaesthetists and nurses, as well as guidelines and recommendations from respected organisations. Agreed policies can be achieved through constructive and open communication by surgeons, anaesthetists and nurses. Some nurses may be reluctant to put evidence based preoperative fasting in to practice if clinical guidelines or trust policies are not in place suggests Hung (1992). However patients with factors likely to delay gastric emptying were excluded from this review investigating the effects of shorter fasting periods. So in reality these findings cannot be applied to all patients. Similarly, the Scandinavian Society of Anaesthesiology and Intensive Care Medicine (2006) guidelines and the Royal College of Nurses (2005) recommendations were made for healthy patients. Implementing those guidelines and recommendations is important for professional accountability, but nursing assessment is crucial to identify at risk patients such as those with hiatus hernia, diabetes mellitus and those who are obese. Evaluate the risk and benefit of their shortened preoperative fasting

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and negotiate their fasting periods with theatre staff and anaesthetists. The role of the nurse should be to implement individualised fasting and exercise clinical judgement based on current evidence and their knowledge of the patients, as they spend more time with patients than do theatre staff or anaesthetists. Aspiration pneumonitis is a rare complication of modern general anaesthesia but still carries a small risk, yet patients are still being fasted for excessive periods affecting both physiological and psychological wellbeing. It could be argued that in respect of this practice, nurses could be deemed negligent, and being ignorant of current evidence is not a defence against negligence states Beauchamp and Childress (2001). Nurses belong to a profession whose standards are derived from fundamental ethical principles of autonomy, beneficence and justice further clarifies Beauchamp and Childress (2001). In demonstrating these principles it could be presumed that in exercising their responsibility for patient care, nurse would be concerned to do good and prevent harm to the patient. By researching and implementing evidence based preoperative fasting, patients would not be put at risk but would receive many benefits in the form of reduced anxiety, discomfort, thirst and hunger; reduced

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postoperative nausea and vomiting, and reduced dehydration. Nurses should always act in the patients best interest based on their knowledge, expertise and skills. This places a professional duty on nurses to keep up to date with changes and developments in their clinical field of practice by delivering care based on current evidence based research states the Nursing and Midwifery Council (2004). Nurses should feel empowered to negotiate appropriate fasting periods as equals with anaesthetists and surgeons. They should also feel empowered to instigate change in practice which is reflective of the evidence because, ensuring that nursing practice is evidence based is essential for professional accountability. The Nursing and Midwifery Council (2004) concludes that nurses are personally accountable and answerable for their actions and omissions, irrespective of whether they are using their initiative or following advice or directions from other professionals. Therefore, nurses should see themselves as instigators of change rendering care that is evidence based by ensuring that patients are fasted for an appropriate period of time. It is regarded as an essential part of care that is crucial to the quality of a surgical patients care experience.

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REFERENCE LIST

Agarwall

1989 Fluid Deprivation before Operation: The Effect of a small Drink. Anaesthesiology 44(8): 632-634

American Society of Anaesthesiologists

1999 Practice Guidelines for Preoperative Fasting and the use of Pharmacological Agents for the Prevention of Pulmonary Aspiration: Application to Healthy Patients Undergoing Elective Surgery. Anaesthesiology 96: 742-752

Arndt K

1999 Inadvertent Hypothermia in the Operating Room. Association of Operating Room Nurses Journal 70: 204-206

Beauchamp TL & Childress Chapman A

2001 Principles of Biomedical Ethics. 5th Ed Oxford University Press, Oxford 1996 Current Theory and Practice: A Study of Pre-Operative Fasting. Nursing Standard 10(18): 33-36

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Department of Health

2005 Total Operations in England 2003-04. Hospital Episodes Statistics DH: London

Duthie G & Gardiner A Flick RP, Schears GJ & Warner MA

2004 Physiology of the Gastrointestinal Tract Whurr Publishers, London 2002 Aspiration in Paediatric Anaesthesia: Is the a Higher Incidence Compared with Adults? Current Opinion in Anaesthesiology 15(3): 323-327

Hamilton Smith SH

1972 Nil by Mouth? RCN, London

Hillier M

2006 Exploring the Evidence around Preoperative Fasting Practices. Nursing Times 102(28) 36-38

Hung P

1992 Preoperative Fasting. Nursing Times 88(48): 57-60

Jester R & Williams R

1999 Pre-Operative Fasting: Putting Research Into Practice. Nursing Standard 13(39): 33-35

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Mellin-Olsen J Fasting J & Gisvold SE

1996 Routine Preoperative Gastric Emptying is Seldom Indicated. A Study of 85,594 Anaesthetics with Special Focus on Aspiration Pneumonia. Anaesthesiologica Scandinavica 40(10): 1184-1188

Mendelson CL

1946 Aspiration of Stomach Contents into Lungs during Obstetric Anaesthesia. American Journal of Obstetric Gynaecology 52: 191-203

Ng A & Smith G

2002 Anaesthesia and the Gastrointestinal Tract Journal of Anaesthesia 16(1): 51-64

Nursing & Midwifery Council OCallaghan N

2004 Code of Professional Conduct. NMC, London 2002 Preoperative Fasting. Nursing Standard 16(36): 33-37

Olsson GL

1986 Aspiration during Anaesthesia: A Computer Aided Study of 185,358 Anaesthetics. Anaesthesiologica Scandinavica 30: 84-92
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Oshodi TO

2004 Clinical Skills: An Evidence Based Approach to Preoperative Fasting British Journal of Nursing 13(16) 958-962

Owens R

2002 Development of communication, Language and Speech. In G Shames & N Anderson (Eds.) Human Communication Disorders: An introduction 6th Ed. Allyn and Bacon: Boston

Pandit VA & Pandit SK

1997 Fasting before and after Ambulatory Surgery. Journal of Peri-Anaesthesia Nursing 12(3): 181-187

Philips S

1993 Pre-Operative Drinking does not affect Gastric Contents. British Journal of Anaesthesia 70(1): 6-9

Rowe J

2000 Preoperative Fasting: Is it Time for a Change? Nursing Times 96(17): 14-15

Royal College of Nursing

2005 Perioperative Fasting in Adults and Children. An RCN Guideline for the Multidisciplinary Team. RCN, London

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Scandinavian Society of Anaesthesiology & Intensive Care Medicine Seymour S

2006 Scandinavian Guidelines for Preoperative Fasting in Elective Patients. SSAI, Stockholm 2000 Preoperative Fluid Restrictions: Hospital Policy and Clinical Practice. British Journal of Nursing 9(14): 925-930

Soreide E & Ljungqvist

2006 Modern Preoperative Fasting Guidelines: A Summary of the Present Recommendations and Remaining Questions. Best Practice & Research Clinical Anaesthesiology 20(3): 483-491

Thomas A

1987 Pre-Operative Fasting: A Question of Routine? Nursing Times 83(49): 46-47

Wicker P & ONeil J

2006 Caring for the Perioperative Patient Blackwell Publishing, Oxford

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APPENDIX 1

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APPENDIX 2

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